Derek Atkinson:Welcome to The Patient Safety Huddle presented by the VA National Center for Patient Safety. I'm your host, Derek Atkinson, public affairs officer. Joining me today is Dr. Sarah Krein from the VA Ann Arbor Healthcare Systems Patient Safety Center of Inquiry on enhancing patient safety by preventing device-associated harm.
Hello, Dr. Krein. How are you?
Sarah Krein:I'm doing well, thank [00:00:30] you.
Derek Atkinson:Well, thank you very much for joining us today on The Patient Safety Huddle, and before we get started, could you tell our listeners a little about yourself?
Sarah Krein:Sure, I have a clinical background in nursing, and I'm a health services research career scientist with the VA Ann Arbor Center for Clinical Management Research, a VA-funded health services research center of innovation. I also co-direct the VA Ann Arbor Patient Center of Inquiry along with Dr. Sanjay Saint, which focuses on enhancing patient safety by preventing device-associated [00:01:00] harm.
Derek Atkinson:Well, let's get right into it. What is device-associated harm, and how prevalent is it?
Sarah Krein:Well, there's a lot of devices used in healthcare, but our specific focus in on some of the most commonly used devices, which for many years have been viewed as fairly innocuous and often overlooked as a source of potential patient harm. These devices are urinary catheters and peripherally-inserted central catheters, which are also called PICCs. While both of these devices play an important role in providing care for patients, they can also result [00:01:30] in both infectious and non-infectious harms.
For urinary catheters, this can include catheter-associated urinary tract infection but also non-infectious complications including trauma, bladder [inaudible 00:01:42], and impaired mobility. With PICCs, complications can include central line-associated bloodstream infection and venous thromboembolism.
Derek Atkinson:What is the Ann Arbor Patient Safety Center of Inquiry, or PSCI, doing to address this problem?
Sarah Krein:Well, there's a lot of things we [00:02:00] have done and are doing to reduce the risk of complications associated with both urinary catheters and PICCs. One common strategy that we've employed for both devices is to develop appropriateness criteria for when a specific device might be warranted. Dr. JenniferMeddings has led an effort that draws upon the literature and expert opinion to define appropriateness criteria for using indwelling urinary catheters or alternatives, such as external or condom catheters, for medical patients and more recently, for surgical [00:02:30] patients.
In a similar process led by Dr. Vineet Chopra focused on vascular devices, including PICCs, resulting in what's called The Michigan Appropriateness Guide for Intravenous Catheters or The MAGIC Criteria. We also realize that simply having these criteria is not enough, so we've also been focusing on developing and testing and implementing strategies to support the use of these criteria, primarily in the hospital setting. This includes things like the use of order sets, documentation templates, and simple decision support tools.
Derek Atkinson:[00:03:00] What are the specific goals of the PSCI?
Sarah Krein:Our specific goal is, of course, to enhance the safety of veterans by promoting the appropriate use of these two medical devices, both urinary catheters and peripherally-inserted central catheters, and to reduce hospital-acquired complications associated with these devices. More broadly, we also wanna develop interventions and implementation strategies to prevent a range of healthcare-associated complications.
Derek Atkinson:What are your findings thus far?
Sarah Krein:The work that [00:03:30] I've been describing is building up prior work that included implementation of what was affectionately known as The Bladder Bundle, which resulted in reductions in catheter-associated urinary tract infection rates in both VA and non-VA hospitals across the country. However, one of the findings from that work was that these reductions were primarily in acute care wards, and there was little if any change in intensive care units. Our current efforts are now focusing on implementing appropriateness criteria more on specific areas, [00:04:00] such as the ICU and in specific populations, such as the use of catheters in surgical patients.
We've also focused on reducing catheter-associated UTI, also known as CAUTI in nursing homes, and this included, with the support of NCPS, the participation of about 60 VA community living centers in the national collaborative that resulted in a significant reduction in CAUTI rates among non-VA nursing homes. Interestingly, in this program, there was no change in rates among the VA [00:04:30] CLCs, but what we found instead was that the VA was actually ahead of the game and had begun working on preventing CAUTI several years before their non-VA counterparts and had already experienced a substantial reduction. The non-VA nursing homes were just catching up with respect to prevention efforts in reducing CAUTI.
Lastly, the work on PICCs is really still emerging, but in addition to developing some tools to support use of the MAGIC criteria, we've also been doing some qualitative work to better understand the context [00:05:00] related to PICC use in VA and really have some interesting preliminary data, which we hope to expand on through some research funding from HSR&D. What this data shows is a lot of diversity, as you might imagine, in VA with respect to how decisions are made about PICC use: who inserts the devices at a given medical center and the types of alternatives that might be available, which are very important considerations when you want to ensure appropriate and safe use of this device.
Derek Atkinson:Well, it sounds like the Ann Arbor PSCI has really done quite a bit on this topic, and I guess [00:05:30] I'm wondering where do you guys go now?
Sarah Krein:That's a very good question. Right now we're really still developing and testing a variety of tools to promote appropriate urinary catheter and PICC use at our local VA but plan to expand some of these efforts to some of the medical centers within our VISN, which is VISN 10, and eventually to medical centers the VA.
However, we are also always looking for other improvement opportunities and ways to promote safer care for veteran. As an example, we've also been conducting a survey of VA and [00:06:00] non-VA hospitals since 2005 that collects information about the use of a number of healthcare-associated infection prevention practices. Our most recent survey was just completed, and we're gonna be analyzing those data to determine not only how VA hospitals compare with non-VA hospitals but also areas to target for potential improvement.
We also have work underway in other areas, such as nurse/physician communication that we think can be used to further support our efforts to reduce device-associated complications and ensure [00:06:30] safe, high quality care for veterans.
Derek Atkinson:Is there anything else that you'd like to mention that perhaps we missed?
Sarah Krein:I think the only thing that I'd also want to mention is that we consider the VA as a model for improving safety and reducing device-associated complications in work that's being done outside of the US. We have some international collaborations, and some of these efforts have translated into work with the World Health Organization, for example, really building on things that have been done in VA.
Derek Atkinson:Wow, that's incredible. This is really exciting. I look forward [00:07:00] to hearing more about your study in the future and all the work that you guys are doing here at the PSCI. Dr. Krein, thank you for joining us today on The Patient Safety Huddle.
Sarah Krein:Thank you. It's been a pleasure.
Speaker 3:To learn more about the VA Ann Arbor Healthcare Systems Patient Safety Center of Inquiry, please visit For more information about the Patient Safety Centers of Inquiry or PSCI Program, please visit [00:07:30] gov.
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